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Many Eligible for Child Health Plan Have No Idea

Cassie O. Halls children, Darren and Tayana, qualify for a plan that provides subsidized insurance to families of the working poor.Credit
Jeremy M. Lange for The New York Times

GREENSBORO, N.C. — During the four years that her children were uninsured, Cassie O. Hall used the emergency room as their pediatrician. When Tayana had an asthma attack or Darren developed a stubborn rash, they would head to the hospital and settle in for a long wait.

The children never got physical exams or booster shots. And as the unpaid hospital bills stacked up, the threshold for a visit grew higher. “They would have to be half-dead before I would take them,” said Ms. Hall, a day care operator who could not afford private insurance.

It was only in May that Ms. Hall learned that her family qualified for the State Children’s Health Insurance Program, which provides subsidized insurance to children of the working poor. That she had never heard of the joint state and federal program made her typical of countless parents of the estimated eight million uninsured children.

Despite a decade of marketing efforts by governments and private foundations, nearly 30 percent of children who are eligible for the health insurance program and are not covered by private plans have yet to enroll, according to a new government study.

Late last week, the Bush administration published new standards intended to prevent states from expanding eligibility for the program to cover children from middle-class families. But a more fundamental debate over the program has been raging in Washington for months: how to find and enroll the 1.7 million low-income children who are already eligible but have not signed up.

That hard-to-reach population is the focus of a showdown over reauthorizing the 10-year-old program, the largest single extension of government-subsidized health insurance since the Great Society health initiatives of 1965.

The challenge of enrolling those already eligible demonstrates how difficult it will be for states to meet the new standards. The policy says that states can expand eligibility only if they have first enrolled 95 percent of those who now qualify. Few states have come close to doing that; the national enrollment rate in 2004-2005 was 72 percent, according to the study.

The Democratic-controlled House and Senate passed varying bills earlier this month that would vastly increase financing for the program, which expires on Sept. 30. Almost all of the new money would be dedicated to finding and covering children who are already eligible.

The federal government shares financing for the program with the states, picking up about 70 percent of total costs. The Senate measure would add an average of $7 billion a year to the $5 billion currently being spent. The House version is even richer, adding an average of $10 billion a year for five years.

President Bush, who proposed a much smaller increase of $1 billion a year, depicts both measures as a major step toward nationalized health coverage and has vowed to veto them.

Administration officials warn that the expansion envisioned by Congress would transform the program into a broad entitlement. Many families, they predict, would cancel private insurance in favor of government coverage (one study found that 14 percent of enrollees did).

Though eligibility varies by state, the 6.6 million children covered by the program typically come from families between 100 percent and 200 percent of the poverty level (between $20,650 and $41,300 for a family of four). Another 29.5 million children, most living below the poverty line, are covered by Medicaid. Studies have found that about two-thirds of all uninsured children are eligible for one of the two programs.

There is little dispute among experts that the program has been instrumental in reducing the rate of uninsurance among low-income children by almost a third, even as the rate for adults has climbed. About 16 percent of children from families with incomes below 200 percent of the federal poverty level were without insurance in 2005, down from 23 percent in 1997, according to a federal government analysis.

But the persistence of so many children without insurance frustrates both policy experts and frontline social service workers.

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Cynthia Neely was surprised to learn that her son, Anthony, was eligible for coverage.Credit
Jeremy M. Lange for The New York Times

“We’ve beat the bushes every which way but loose to find these kids,” said Janice G. Cardin, the supervisor here in Guilford County for North Carolina Health Choice, as the state’s program is called. “But we know there are still a lot of them out there.”

In this county, as across North Carolina, outreach workers are once again distributing fliers as school starts. They have used radio advertisements and refrigerator magnets, and have partnered with minority groups like Lumbee Indians and Hmong refugees.

They have staffed tables at health fairs and plants that are shedding workers. They have eliminated waiting periods, simplified application and income verification procedures, and provided translators to immigrants.

And yet, the rate of children without insurance in the state recently reversed course and began rising, to 12.5 percent in 2005 from 10.6 percent in 2004, according to the North Carolina Institute of Medicine. Though the Health Choice program now covers about 113,000 North Carolina children, the rate of uninsurance today is the same as in 1999.

Researchers at the Urban Institute, an independent group that studies economic and social issues, recently calculated that 5.4 million children nationwide were uncovered at some point each year despite being eligible for government insurance. The nonpartisan Congressional Budget Office endorses the calculation.

But the Bush administration has embraced a finding by a different set of Urban Institute researchers that only 1.1 million children fall into that category, a figure based on those without insurance for an entire year.

“My perspective is that all states have been extremely successful, which is why we have so few left who are eligible but have not been found,” said Dennis G. Smith, director of the Center for Medicaid and State Operations.

As it is, administration officials say, the creation of the program, along with increased use of Medicaid and a decline in employer-based coverage, has resulted in a significant shift to government insurance. Forty-five percent of all children were covered by the insurance program or Medicaid in 2005, up from 28 percent in 1998, according to the Health and Human Services Department.

They are families like the Neelys of nearby High Point, N.C., a city still recovering from losses in its textile and furniture industries. After 15 years as an account manager for American Express, Cynthia L. Neely found herself laid off last December, and her husband could not afford his employer’s insurance.

Ms. Neely said she was relieved and surprised to learn this month that her 8-year-old son had qualified for Health Choice.

“I’ve worked since I was 15 and I never thought I would need this,” she said. “I always thought if you had any income at all in your household that you wouldn’t qualify.”

That misconception is among the obstacles to signing up children of working parents. For Hispanic parents, there may be barriers of language and immigration status. In other instances, parents may struggle with the stigmatizing perception that they might be taking welfare.

The Bush administration complains that many states have distorted the original intent of the program by raising eligibility limits to as high as 350 percent of poverty (New Jersey, with New York seeking federal approval to go to 400 percent).

Enrollment in the program grew rapidly in its early years, but slowed in 2003 and dipped briefly in 2004 before recovering the next year. Various studies have blamed state budget cuts for the slowdown, which prompted some states to restrict eligibility and make enrollment cumbersome. In North Carolina, budget-cutters temporarily froze Health Choice enrollment in 2001. In Texas, where one of every five children is uninsured, officials began requiring parents to requalify for the program every six months rather than annually.

But as fiscal pressures eased in the last two years, states have revived efforts to increase enrollment through measures like allowing applicants to mail in forms and requiring less documentation of income.

A version of this article appears in print on , on page A1 of the New York edition with the headline: Eligible for Health Insurance, Many Families Have No Idea. Order Reprints|Today's Paper|Subscribe